Doctors use 3D technology to enhance art of medicine

As high-tech as the equipment and treatments can be at MUSC Health, doctors know they must keep the art of medicine at the heart of what they do.

That blend of technology and art is exemplified in cases like that of 5-year-old Rhett Bausmith, who’s been a patient at MUSC Health since he was 5 days old. The surgeries he endured as an infant and toddler were medical necessities to deal with craniosynostosis, a birth defect that causes the bones in a baby’s skull to fuse too early, which then impedes brain growth and deforms the facial structure as the bones in the face continue to grow.

Once he was past those initial surgeries, though, Rhett’s doctors and parents had to navigate a careful path forward, balancing medical, psychological and aesthetic considerations as they periodically consulted and determined the next steps for Rhett’s treatment.

 

There’s a different balance with each patient and each family, said pediatric neurosurgeon Ramin Eskandari, M.D. Eskandari regularly operates on the cutting edge, enthusiastically introducing new technologies and techniques to his department. But he also knows that high-tech machinery can’t make the difficult decision to allow a surgeon once again to cut open your child’s skull.

“When decisions like this no longer revolve around urgent medical necessity, the art of medicine kicks in. The family and the patient and their perspectives, expectations and general wishes are central to the decision making, and the best outcomes arise when we make those decisions together as a team with the family,” he said.

In Rhett’s case, it was clear that his skull was still not growing properly. Eskandari and plastic surgeon Jason Ulm, M.D., had anticipated that could happen when they performed the first series of surgeries. Because young children’s bones grow so quickly, doctors can usually get a better cosmetic outcome if they wait until the child is a little older and the shape of the face and head has taken on a more mature look.

But because Rhett’s craniosynostosis was so severe, they couldn’t postpone his first operations. The first series of operations tended to the removal of the fused sagittal and left coronal sutures, which shouldn’t close until around 2 years of age. But the bone regrew quickly, Eskandari said, and grew flat instead of in the normal rounded shape. That meant Rhett’s frontal lobe didn’t have the proper amount of space to grow. One of his eye sockets, too, wasn’t shaped properly, and as Rhett grew older, he had started to take note that his face was different than everyone else’s, said his mother, Crystal Bausmith, who would see him looking in the mirror and touching his eyebrow.

Luckily, Rhett hasn’t had any cognitive delays. He started kindergarten last fall, plays youth baseball and enjoys a weekly Sunday dinner with extended family. He is, Crystal said, a delightful, sweet little boy.

But beyond the day to day of raising five children, Crystal and husband, Timothy, have had to wrestle with the best time for the next operation. It was a difficult decision, Eskandari explained. The longer they waited, the more likely they would have a good cosmetic outcome and wouldn’t have to repeat surgeries because of bone regrowth in the wrong places. But it wasn’t clear how long they could wait without jeopardizing Rhett’s executive functioning skills.

“The literature is sort of helpful – but not really – because it doesn’t talk about functional outcome or brain development. It mostly talks about the bones and cosmetics,” Eskandari explained.

Ultimately, the Bausmiths and the doctors decided to operate in November. As with the initial surgeries, Eskandari and Ulm enlisted the help of the Zucker Institute for Applied Neurosciences, a technology accelerator embedded within MUSC, to create a 3D model of Rhett’s skull.

A low-dose CT scan, which emitted radiation equivalent to what one would receive on a cross-country flight, still provided clear enough pictures of the skull for ZIAN to use with the 3D printer. Once the 3D skull model was complete, Eskandari and Ulm could then determine the best way to achieve the result they wanted.

“There's a whole bunch of different ways you could go about making the skull look normal. But there’s certain restrictions on what we can physically remove,” Eskandari said. “Having that 3D model allowed us to see exactly where we needed to make our cut lines and how much we actually had to work with as far as reconstruction.”

 

For example, he said, one way to fix the eye socket would be to place bone on top and allow it to build up. The model, however, showed that that method still wouldn’t give Rhett’s brain enough space. The model also helped them to figure out just how much of the skull needed to be reconstructed and, importantly, what could be left alone. That meant a shorter surgery with less blood loss, Eskandari said. Eskandari and Ulm even brought the model into the operating room.

Once they began the surgery, they saw just how much pressure Rhett’s frontal lobe was under. His skull had all the classic features of what’s known as “copper beaten skull,” named for the texture of hammered copper. Those indentations in the bone indicated that the brain was pushing against the immoveable skull as it grew, he said.

Eskandari said they’re hopeful this will be the last reconstruction surgery that Rhett will need.

 

His parents are hopeful, too. This surgery was in many ways more difficult for Rhett than the earlier ones because he was more aware of what was happening. But after almost a week at the MUSC Shawn Jenkins Children’s Hospital, he was able to return home. Now, two months after surgery, he’s doing well and back to doing everything that a 5-year-old wants to do, Crystal said.

“Dr. Eskandari and Dr. Ulm have done a great job with him. We have been very blessed to have them be our doctors,” she said.